Core IM podcast: 5 Pearls on Iron Deficiency Anemia

November 15, 2017

CORE IM Podcast GI Heme/Onc Uncategorized 3 min read

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Listen to 5 Pearls segment of Iron Deficiency Anemia! By Dr. Cary Blum MD, Marty Fried MD and Shreya P. Trivedi MD; Illustration by Mike Natter MD

Time Stamps:

  1.  Should patients be screened for iron deficiency? If so, who and how often? (1:40)
  2.  What are the indications for diagnostic endoscopy in iron deficient patients? (3:23)
  3. How should you advice patients to take oral iron? What is optimal dosing? (5:53)
  4.  In which patients would you consider IV iron? What are the risks? (11:41)
  5.  Throwback Question: What is a medication overuse HA? (14:44)

Pearl 1:

  1. Asymptomatic patients at high risk of IDA should probably be screened, but this recommendation is not evidence based and is based on outdated professional society guidelines.
  2. The interval of repeat screening is also not clear.

Pearl 2:

  1. Men and post-menopausal women without any history of overt bleeding should be referred to scope from both upper and lower endoscopy.
  2. In these populations, there is an increased chance of malignancy, and an even greater chance of other GI pathology that can be intervened on.

Pearl 3:

  1. The exact optimal dose of oral iron is not known and likely depends on the individual patient.
  2. When choosing a dose, one should consider the pharmacology of hepcidin-induced malabsorption and balance this with the patient’s side effect burden.
  3. Patients should be instructed to NOT take it with food and if possible with vitamin C or citrus food.

Pearl 4:

  1. Newer formulations of IV iron are safer and without increased risk for significant adverse reaction or infection.
  2. It is quicker and more effective than oral iron in repleting stores.
  3. IV iron should be considered in patients who are poorly tolerating oral Fe SE, have malabsorption disease, ESRD or with ongoing blood loss that oral iron cannot keep up with.

Pearl 5:

  1. If you notice your patient’s headache changes from intermittent to a chronic, daily headache while using lots of abortive therapy medications, consider medication overuse headache.
  2. To avoid medical overuse headache, encourage your patient to limit triptans and NSAIDs to less than 2 times per week on average.
  3. Don’t confuse medication overuse headache with a medication induced headache, which is most common drugs seen with drugs like  nitrates, phosphodiesterase inhibitors, and hormones.

Many thanks to Dr. Poles and Dr. David Green for peer-reviewing this podcast!

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References:

  1. Stoltzfus, Rebecca J., and Michele L. Dreyfuss. Guidelines for the use of iron supplements to prevent and treat iron deficiency anemia. Vol. 2. Washington^ eDC DC: Ilsi Press, 1998.
  2. Iron Deficiency Anemia Prevention. “Recommendations to prevent and control iron deficiency in the United States.” MMWR: Morbidity & Mortality Weekly Report. 47 (1998): 1-29.
  3. “Guidelines for the Management of Iron Deficiency Anemia,” British society of gastroenterology, BMJ, 2011.
  4.  Yates JM, Logan EC, Stewart RM. Iron deficiency anaemia in general practice: clinical outcomes over three years and factors influencing diagnostic investigations. Postgrad Med J. 2004;80(945):405–410.
  5. Ioannou GN, Rockey DC, Bryson CL, Weiss NS. Iron deficiency and gastrointestinal malignancy: a population-based cohort study.Am J Med. 2002;113(4):276.
  6. Brise H, Hallberg L. Absorbability of different iron compounds. Acta Med Scand Suppl 1962;376: 23-37.
  7. Rimon E, Kagansky N, Kagansky M, et al. Are we giving too much iron? Low-dose iron therapy is effective in octogenarians. Am J of Med 2005;118(10): 1142-1147
  8. Auerbach M, Adamson JW. How we diagnose and treat iron deficiency anemia. Am J Hematol. 2016;91(1):31.
  9. Avni T, Bieber A, Grossman A, Green H, Leibovici L, Gafter-Gvili A. The safety of intravenous iron preparations: systematic review and meta-analysis. Mayo Clin Proc2015;90:12-23. 10.1016/j.mayocp.2014.10.007
  10. Munksgaard SB, Jensen RH. “Medication overuse headache.” Headache. 2014: 807-22.